Endoscopic management of surgical complications.

While the endoscopic management of surgical complications like leaks, fistulas, and perforations is rapidly evolving, its core principles revolve around closure, drainage, and containment. Effectively managing these conditions relies on several factors, such as the underlying cause, chronicity of the lesion, tissue viability, co-morbidities, availability of devices, and expertise required to perform the endoscopy. In contrast to acute perforation, fistulas and leaks often demand a multimodal approach requiring more than one session to achieve the required results. Although the ultimate goal is complete resolution, these endoscopic interventions can provide clinical stability, enabling enteral feeding to lead to early hospital discharge or elective surgery. In this discussion, we emphasize the current state of knowledge and the prospective role of endoscopic interventions in managing surgical complications.

The influence of postoperative outcomes on survival after esophageal cancer surgery: validation of a consensus-based updated textbook outcome parameter.

BACKGROUND: Esophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for esophageal adenocarcinoma. The primary aim of this study was to assess the influence of textbook outcome (TO) as a composite quality performance indicator (QPI) and its perioperative parameters on survival in patients who underwent esophagectomy with curative intent. METHODS: Consecutive patients who underwent an esophagectomy between January 2014 and December 2022 at Christchurch Hospital were identified from a prospectively maintained hospital database. Univariable and multivariable analyses were performed to assess prognostic factors for each composite and individual postoperative outcome. Survival analysis was performed to evaluate the influence of these outcomes on overall survival. RESULTS: A total of 108 patients underwent an esophagectomy during the study period. The overall and Clavien-Dindo (CD) grade ≥ 3 postoperative complication rates were 62% and 26%, respectively. The anastomotic leak rate was 6.5% (n = 7). The TO rate, 30-day readmission rate, and 30-day mortality rate were 20%, 13%, and 1%, respectively. Resection margin and nodal disease were found to be independent prognostic factors for reduced survival. CONCLUSION: TO as originally defined and its postoperative parameters of 30-day postoperative complications and 30-day readmission are validated QPIs of esophageal cancer surgery. Updating the postoperative complication parameter to include CD grade ≥ 3 complications resulted in a positive association between achieving TO and increased survival. Our findings support the call to redefine TO based on an update to this parameter, making it a more precise QPI of esophageal cancer surgery.

Minor impact of anastomotic leakage in anterior resection for rectal cancer on long-term male urinary and sexual function.

PURPOSE: Anastomotic leakage after anterior resection for rectal cancer induces bowel dysfunction, but the influence on urinary and sexual function is largely unknown. This cross-sectional cohort study evaluated long-term effect of anastomotic leakage on urinary and sexual function in male patients. METHODS: Patients operated with anterior resection for rectal cancer in 15 Swedish hospitals 2007-2013 were identified. Anastomotic leakage and other clinical variables were retrieved from the Swedish Colorectal Cancer Registry and medical records. Urinary and sexual dysfunction were evaluated at 4 to 11 years after surgery using the International Prostate Symptom Score, International Index of Erectile Function, and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire CR29. The effect of anastomotic leakage on average scores of urinary and sexual dysfunction was evaluated as a primary outcome, and the single items permanent urinary catheter and sexual inactivity as secondary outcomes. The association of anastomotic leakage and functional outcomes was analyzed using regression models with adjustment for confounders. RESULTS: After a median follow-up of 84 months (interquartile range: 67-110), 379 out of 864 eligible men were included. Fifty-nine (16%) patients had anastomotic leakage. Urinary incontinence was more common in the leakage group, with an adjusted mean score difference measured by EORTC QLQ ColoRectal-29 of 8.69 (95% confidence interval: 0.72-16.67). The higher risks of urinary frequency, permanent urinary catheter, and sexual inactivity did not reach significance. CONCLUSION: Anastomotic leakage after anterior resection had a minor negative impact on urinary and sexual function in men.

[Prospects of qualitative and quantitative assessment of bowel perfusion by fluorescent angiography with indocyanine green in colorectal surgery. First experience]. / Perspektivy kachestvennoi i kolichestvennoi otsenki perfuzii kishki metodom flyuorestsentnoi angiografii s indotsianinom zelenym v kolorektal'noi khirurgii. Pervyi opyt.

OBJECTIVE: To assess the possibilities of fluorescent detection system in qualitative and quantitative assessment of bowel perfusion in colorectal resections. MATERIAL AND METHODS: From May to August 2023, a single-center pilot cross-sectional unblinded study with inclusion of 18 patients with colon cancer (of left-sided - 12, of right-sided - 6, mean age - 72.9 years, m/w - 61/39%) was conducted. All patients underwent laparoscopic colorectal resections with extracorporeal stage of bowel transection. The evaluation of the bowel's ICG perfusion was conducted to assist in decision making about the level of its resection. Qualitative (visual) assessment was carried out in all 18 patients, in one patient twice, quantitative assessment of perfusion was conducted in 8 patients (left-sided resections - 6, right-sided hemicolectomy - 2). The qualitative evaluation was performed in real time on the analysis of the color gradient. The time parameters and fluorescence intensity at different level proximally and distally from the resection line were quantitatively estimated: Tstart - time of occurrence of minimal fluorescence in the areas of interest after the ICG injection (sec); Tmax - time to achieve maximum fluorescence intensity after the ICG injection (sec); Tmax-start - time interval between Tstart and Tmax, Imax - level of maximum fluorescence intensity (I). RESULTS: Visual qualitative analysis of fluorescence revealed unsatisfactory perfusion characteristics (black, dark-gray color) in the area planned by the surgeon to anastomose the bowel in 3 of 18 patients (16.6%). When analyzing the quantitative data of this group of patients, there was a 2-6-fold decrease in Imax level, and one patient had an increase in Tmax-start at the level of intended resection compared to the bowel's sections in the favorable zone. In all cases, the final bowel transection was conducted in the area of good perfusion. There was no clinical evidence of anastomotic dehiscence in the study group. CONCLUSION: Intraoperative evaluation of bowel perfusion is an important component of safe anastomosis formation in colorectal surgery. The use of ICG-FA allows to conduct qualitative and quantitative assessment of tissue perfusion of the bowel in order to assist in making intraoperative decisions. Quantitative evaluation of fluorescence provides more objective information about perfusion parameters. Imax and Tmax-start are the most promising quantitative indicators of local bowel's perfusion. Nevertheless, the precise interpretation of the quantitative indicators of ICG perfusion needs to be clarified.

Routine Upper Gastrointestinal Series Post-bariatric Surgery: Predictors, Usage, and Utility.

OBJECTIVE: To investigate usage and utility of routine upper gastrointestinal (UGI) series in the immediate post-operative period to evaluate for leak and other complications. METHODS: Single institution IRB-approved retrospective review of patients who underwent bariatric procedure between 01/08 and 12/12 with at least 6-month follow-up. RESULTS: Out of 135 patients (23%) who underwent routine UGI imaging, 32% of patients were post-gastric bypass (127) versus 4% of sleeve gastrectomy (8). In patients post-gastric bypass, 22 were found with delayed contrast passage, 3 possible obstruction, 4 possible leak, and only 1 definite leak. In patients post-sleeve gastrectomy, 2 had delayed passage of contrast without evidence of a leak. No leak was identified in 443 patients (77%) who did not undergo imaging. The sensitivity and specificity of UGI series for the detection of leak in gastric bypass patients were 100% and 97%, respectively, and the positive and negative predictive values were 20% and 100%, respectively. On univariate and multivariate analysis, sleeve gastrectomy patients (OR 0.4 sleeve vs bypass; P < 0.01) and male patients (OR 0.4 M vs F; P 0.02) were less likely to undergo routine UGI series (OR 0.4 M vs F; P 0.02). CONCLUSION: Routine UGI series may be of limited value for the detection of anastomotic leaks after gastric bypass or sleeve gastrectomy and patients should undergo routine imaging based on clinical parameters. Gastric bypass procedure and female gender were factors increasing the likelihood of routine post-operative UGI. Further larger scale analysis of this important topic is warranted.

Blood flow evaluation of reconstructed gastric tube in esophageal surgery using near-infrared imaging and retrospective time-intensity curve analysis.

PURPOSE: Near-infrared fluorescence imaging using indocyanine green (ICG-NIFI) can visualize a blood flow in reconstructed gastric tube; however, it depends on surgeon's visual assessment. The aim of this study was to re-analyze the ICG-NIFI data by an evaluator independent from the surgeon and feasibility of creating the time-intensity curve (TIC). METHODS: We retrospectively reviewed 97 patients who underwent esophageal surgery with gastric tube reconstruction between January 2017 and November 2022. From the stored ICG videos, fluorescence intensity was examined in the four regions of interest (ROIs), which was set around the planned anastomosis site on the elevated gastric tube. After creation the TICs using the OpenCV library, we measured the intensity starting point and time constant and assessed the correlation between the anastomotic leakage. RESULTS: Postoperative leakage occurred for 12 patients. The leakage group had significantly lack of blood flow continuity between the right and left gastroepiploic arteries (75.0% vs. 22.4%; P < 0.001) and tended to have slower ICG visualization time assessed by the surgeon's eyes (40 vs. 32 s; P = 0.066). TIC could create in 65 cases. Intensity starting point at all ROIs was faster than the surgeon's assessment. The leakage group tended to have slower intensity starting point at ROI 3 compared to those in the non-leakage group (22.5 vs. 19.0 s; P = 0.087). CONCLUSION: A TIC analysis of ICG-NIFI by an independent evaluator was able to quantify the fluorescence intensity changes that the surgeon had visually determined.

The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis.

BACKGROUND: Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches. METHODS: A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess. RESULTS: Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders. DISCUSSION: This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.

Placing vacuum sponges in esophageal anastomotic leaks - how we do it.

PURPOSE: Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult. METHODS: We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits. RESULTS: Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation. CONCLUSION: We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion.

Impact of Arteriosclerosis on Reconstruction-related Complications After Esophagectomy and Usefulness of Tailor-made Reconstruction Technique.

BACKGROUND/AIM: Anastomotic leakage is one of the most common and serious postoperative complications following esophagectomy. This study analyzed the effect of risk factors, such as the degree of arteriosclerosis, comorbidities, and patient characteristics on the incidence of reconstruction-related complications including anastomotic leakage. Furthermore, the usefulness of tailor-made reconstruction methods was clarified using wide gastric conduit. PATIENTS AND METHODS: Patients who underwent esophagectomy with a gastric conduit for esophageal cancer between 2011 and 2018 were enrolled. In the initial group that underwent esophagectomy between August 2011 and February 2016, gastrointestinal reconstruction was performed using a narrow gastric conduit. In the latter group, reconstruction using subtotal gastric conduit was selected for high-risk patients between March 2016 and March 2018. Postoperative complications including reconstruction-related complications were assessed. RESULTS: The occurrence of anastomotic leakage was significantly associated with the patient's risk in the initial group. The rates of anastomotic leakage and reconstruction-related complications were significantly lower in the latter group than in the initial group (3.2% vs. 23.0%, p=0.001; 27.0% vs. 44.3%, p=0.044). The incidence of all complications was significantly lower in the latter group than in the initial group (28.6% vs. 59.0%, p=0.001). The change in bodyweight loss one year after the operation was significantly lower in the latter group than in the initial group (p=0.042). CONCLUSION: Tailor-made reconstruction using wide gastric conduit for high-risk cases of esophageal cancer could reduce the occurrence of anastomotic leakage and promote a better quality of life after surgery.

Fashioning esophagogastric anastomosis in robotic Ivor-Lewis esophagectomy: a multicenter experience.

BACKGROUND: The aim of the present study is to compare outcomes of the robotic hand-sewn, linear- and circular-stapled techniques performed to create an intrathoracic esophagogastric anastomosis in patients who underwent Ivor-Lewis esophagectomy. METHODS: Patients who underwent a planned Ivor-Lewis esophagectomy were retrospectively analysed from prospectively maintained databases. Only patients who underwent a robotic thoracic approach with the creation of an intrathoracic esophagogastric anastomosis were included in the study. Patients were divided into three groups: hand-sewn-, circular stapled-, and linear-stapled anastomosis group. Demographic information and surgery-related data were extracted. The primary outcome was the rate of anastomotic leakages (AL) in the three groups. Moreover, the rate of grade A, B and C anastomotic leakage were evaluated. In addition, patients of each group were divided in subgroups according to the characteristics of anastomotic fashioning technique. RESULTS: Two hundred and thirty patients were enrolled in the study. No significant differences were found between the three groups about AL rate (p = 0.137). Considering the management of the AL for each of the three groups, no significant differences were found. Evaluating the correlation between AL rate and the characteristics of anastomotic fashioning technique, no significant differences were found. CONCLUSIONS: No standardized anastomotic fashioning technique has yet been generally accepted. This study could be considered a call to perform ad hoc high-quality studies involving high-volume centers for upper gastrointestinal surgery to evaluate what is the most advantageous anastomotic technique.

Uncut Roux-en-Y reconstruction after distal gastrectomy for gastric cancer.

BACKGROUND: Choosing an optimal reconstruction method is pivotal for patients with gastric cancer undergoing distal gastrectomy. The uncut Roux-en-Y reconstruction, a variant of the conventional Roux-en-Y approach (or variant of the Billroth II reconstruction), employs uncut devices to occlude the afferent loop of the jejunum. This modification is designed to mitigate postgastrectomy syndrome and enhance long-term functional outcomes. However, the comparative benefits and potential harms of this approach compared to other reconstruction techniques remain a topic of debate. OBJECTIVES: To assess the benefits and harms of uncut Roux-en-Y reconstruction after distal gastrectomy in patients with gastric cancer. SEARCH METHODS: We searched CENTRAL, PubMed, Embase, WanFang Data, China National Knowledge Infrastructure, and clinical trial registries for published and unpublished trials up to November 2023. We also manually reviewed references from relevant systematic reviews identified by our search. We did not impose any language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs comparing uncut Roux-en-Y reconstruction versus other reconstructions after distal gastrectomy for gastric cancer. The comparison groups encompassed other reconstructions such as Billroth I, Billroth II (with or without Braun anastomosis), and Roux-en-Y reconstruction. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. The critical outcomes included health-related quality of life at least six months after surgery, major postoperative complications within 30 days after surgery according to the Clavien-Dindo Classification (grades III to V), anastomotic leakage within 30 days, changes in body weight (kg) at least six months after surgery, and incidence of bile reflux, remnant gastritis, and oesophagitis at least six months after surgery. We used the GRADE approach to evaluate the certainty of the evidence. MAIN RESULTS: We identified eight trials, including 1167 participants, which contributed data to our meta-analyses. These trials were exclusively conducted in East Asian countries, predominantly in China. The studies varied in the types of uncut devices used, ranging from 2- to 6-row linear staplers to suture lines. The follow-up periods for long-term outcomes spanned from 3 months to 42 months, with most studies focusing on a 6- to 12-month range. We rated the certainty of evidence from low to very low. Uncut Roux-en-Y reconstruction versus Billroth II reconstruction In the realm of surgical complications, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Billroth II reconstruction may make little to no difference to major postoperative complications (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.24 to 4.05; I² = 0%; risk difference (RD) 0.00, 95% CI -0.04 to 0.04; I² = 0%; 2 studies, 282 participants; very low-certainty evidence) and incidence of anastomotic leakage (RR 0.64, 95% CI 0.29 to 1.44; I² not applicable; RD -0.00, 95% CI -0.03 to 0.02; I² = 32%; 3 studies, 615 participants; very low-certainty evidence). We are very uncertain about these results. Focusing on long-term outcomes, low- to very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Billroth II reconstruction may make little to no difference to changes in body weight (mean difference (MD) 0.04 kg, 95% CI -0.84 to 0.92 kg; I² = 0%; 2 studies, 233 participants; low-certainty evidence), may reduce the incidence of bile reflux into the remnant stomach (RR 0.67, 95% CI 0.55 to 0.83; RD -0.29, 95% CI -0.43 to -0.16; number needed to treat for an additional beneficial outcome (NNTB) 4, 95% CI 3 to 7; 1 study, 141 participants; low-certainty evidence), and may have little or no effect on the incidence of remnant gastritis (RR 0.27, 95% CI 0.01 to 5.06; I2 = 78%; RD -0.15, 95% CI -0.23 to -0.07; I2 = 0%; NNTB 7, 95% CI 5 to 15; 2 studies, 265 participants; very low-certainty evidence). No studies reported on quality of life or the incidence of oesophagitis. Uncut Roux-en-Y reconstruction versus Roux-en-Y reconstruction In the realm of surgical complications, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Roux-en-Y reconstruction may make little to no difference to major postoperative complications (RR 4.74, 95% CI 0.23 to 97.08; I² not applicable; RD 0.01, 95% CI -0.02 to 0.04; I² = 0%; 2 studies, 256 participants; very low-certainty evidence) and incidence of anastomotic leakage (RR 0.34, 95% CI 0.05 to 2.08; I² = 0%; RD -0.02, 95% CI -0.06 to 0.02; I² = 0%; 2 studies, 213 participants; very low-certainty evidence). We are very uncertain about these results. Focusing on long-term outcomes, very low-certainty evidence suggests that uncut Roux-en-Y reconstruction compared with Roux-en-Y reconstruction may increase the incidence of bile reflux into the remnant stomach (RR 10.74, 95% CI 3.52 to 32.76; RD 0.57, 95% CI 0.43 to 0.71; NNT for an additional harmful outcome (NNTH) 2, 95% CI 2 to 3; 1 study, 108 participants; very low-certainty evidence) and may make little to no difference to the incidence of remnant gastritis (RR 1.18, 95% CI 0.69 to 2.01; I² = 60%; RD 0.03, 95% CI -0.03 to 0.08; I² = 0%; 3 studies, 361 participants; very low-certainty evidence) and incidence of oesophagitis (RR 0.82, 95% CI 0.53 to 1.26; I² = 0%; RD -0.02, 95% CI -0.07 to 0.03; I² = 0%; 3 studies, 361 participants; very low-certainty evidence). We are very uncertain about these results. Data were insufficient to assess the impact on quality of life and changes in body weight. AUTHORS' CONCLUSIONS: Given the predominance of low- to very low-certainty evidence, this Cochrane review faces challenges in providing definitive clinical guidance. We found the majority of critical outcomes may be comparable between the uncut Roux-en-Y reconstruction and other methods, but we are very uncertain about most of these results. Nevertheless, it indicates that uncut Roux-en-Y reconstruction may reduce the incidence of bile reflux compared to Billroth-II reconstruction, albeit with low certainty. In contrast, compared to Roux-en-Y reconstruction, uncut Roux-en-Y may increase bile reflux incidence, based on very low-certainty evidence. To strengthen the evidence base, further rigorous and long-term trials are needed. Additionally, these studies should explore variations in surgical procedures, particularly regarding uncut devices and methods to prevent recanalisation. Future research may potentially alter the conclusions of this review.

Laparoscopic total mesorectal excision versus transanal total mesorectal excision for mid and low rectal cancer: A systematic review and meta-analysis.

BACKGROUND: Laparoscopic total mesorectal excision (LaTME) and transanal total mesorectal excision (TaTME) are popular mid and low rectal cancer trends. However, there is currently no systematic comparison between LaTME and TaTME of mid and low rectal cancer. Therefore, we systematically study the perioperative and pathological outcomes of LaTME and TaTME in mid and low rectal cancer. METHODS: Articles included searching through the Embase, Cochrane Library, PubMed, Medline, and Web of science for articles on LaTME and TaTME. We calculated pooled standard mean difference (SMD), relative risk (RR), and 95% confidence intervals (CIs). The protocol for this review has been registered on PROSPERO (CRD42022380067). RESULTS: There are 8761 participants included in 33 articles. Compared with TaTME, patients who underwent LaTME had no statistical difference in operation time (OP), estimated blood loss (EBL), postoperative hospital stay, over complications, intraoperative complications, postoperative complications, anastomotic stenosis, wound infection, circumferential resection margin, distal resection margin, major low anterior resection syndrom, lymph node yield, loop ileostomy, and diverting ileostomy. There are similarities between LaTME and TaTME for 2-year DFS rate, 2-year OS rate, distant metastasis rat, and local recurrence rate. However, patients who underwent LaTME had less anastomotic leak rates (RR 0.82; 95% CI: 0.70-0.97; I2 = 10.6%, P = .019) but TaTME had less end colostomy (RR 1.96; 95% CI: 1.19-3.23; I2 = 0%, P = .008). CONCLUSION: This study comprehensively and systematically evaluated the differences in safety and effectiveness between LaTME and TaTME in the treatment of mid and low rectal cancer through meta-analysis. Patients who underwent LaTME had less anastomotic leak rate but TaTME had less end colostomy. There is no difference in other aspects. Of course, in the future, more scientific and rigorous conclusions need to be drawn from multi-center RCT research.

Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study.

BACKGROUND: Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear. METHODS: After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications. RESULTS: Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels. CONCLUSIONS: Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.

Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy.

BACKGROUND: After esophagectomy, the postoperative rate of anastomotic leakage is up to 30% and is the main driver of postoperative morbidity. Contemporary management includes endoluminal vacuum sponge therapy (EndoVAC) with good success rates. Vacuum therapy improves tissue perfusion in superficial wounds, but this has not been shown for gastric conduits. This study aimed to assess gastric conduit perfusion with EndoVAC in a porcine model for esophagectomy. MATERIAL AND METHODS: A porcine model (n = 18) was used with gastric conduit formation and induction of ischemia at the cranial end of the gastric conduit with measurement of tissue perfusion over time. In three experimental groups EndoVAC therapy was then used in the gastric conduit (- 40, - 125, and - 200 mmHg). Changes in tissue perfusion and tissue edema were assessed using hyperspectral imaging. The study was approved by local authorities (Project License G-333/19, G-67/22). RESULTS: Induction of ischemia led to significant reduction of tissue oxygenation from 65.1 ± 2.5% to 44.7 ± 5.5% (p < 0.01). After EndoVAC therapy with - 125 mmHg a significant increase in tissue oxygenation to 61.9 ± 5.5% was seen after 60 min and stayed stable after 120 min (62.9 ± 9.4%, p < 0.01 vs tissue ischemia). A similar improvement was seen with EndoVAC therapy at - 200 mmHg. A nonsignificant increase in oxygenation levels was also seen after therapy with - 40 mmHg, from 46.3 ± 3.4% to 52.5 ± 4.3% and 53.9 ± 8.1% after 60 and 120 min respectively (p > 0.05). An increase in tissue edema was observed after 60 and 120 min of EndoVAC therapy with - 200 mmHg but not with - 40 and - 125 mmHg. CONCLUSIONS: EndoVAC therapy with a pressure of - 125 mmHg significantly increased tissue perfusion of ischemic gastric conduit. With better understanding of underlying physiology the optimal use of EndoVAC therapy can be determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion.

Redefining Esophagectomy: The Manual Layered Insertion Method That May Reduce Anastomotic Leakage.

INTRODUCTION: Anastomotic leakage post-esophagectomy remains a significant challenge. Despite the use of both mechanical and manual anastomosis, leakage rates remain high. This study evaluated the effectiveness of the manual layered insertion anastomosis technique in addressing this issue. METHODS: A retrospective analysis was conducted on patients who underwent this technique from September 2020 to December 2021. The process involved thoracoscopic release of the esophagus, mediastinal lymph node dissection, laparoscopic stomach release, and its transformation into a tube. The latter was then guided to the neck for anastomosis. The posterior anastomotic wall was reshaped in the neck first for optimal insertion, followed by layered suturing with the gastric conduit. The anterior wall was subsequently sutured and repositioned into the chest. RESULTS: The study included 56 patients (51 men, five women, mean age 65.4 y), with nine having undergone neoadjuvant therapy. All received minimally invasive esophagectomy. Average intraoperative blood loss was 79.8 mL, operation time averaged 331 min, and feeding resumed after an average of 6.3 d. No anastomotic leakages were reported, with reduced incidences of anastomotic stenosis and gastric acid reflux compared to previous studies. CONCLUSIONS: The manual layered insertion anastomosis technique may reduce anastomotic leakage and associated complications, improving the efficacy of esophagectomy, which may improve postoperative results and patient quality of life, suggesting the method's potential suitability for wider clinical application.

Association of omental pedicled flap with anastomotic leak following low anterior resection for rectal cancer.

BACKGROUND AND OBJECTIVES: Anastomotic leak following colorectal anastomosis adversely impacts short-term, oncologic, and quality-of-life outcomes. This study aimed to assess the impact of omental pedicled flap (OPF) on anastomotic leak among patients undergoing low anastomotic resection (LAR) for rectal cancer using a multi-institutional database. METHODS: Adult rectal cancer patients in the US Rectal Cancer Consortium, who underwent a LAR for stage I-III rectal cancer with or without an OPF were included. Patients with missing data for surgery type and OPF use were excluded from the analysis. The primary outcome was the development of anastomotic leaks. Multivariable logistic regression was used to determine the association. RESULTS: A total of 853 patients met the inclusion criteria and OPF was used in 106 (12.4%) patients. There was no difference in age, sex, or tumor stage of patients who underwent OPF versus those who did not. OPF use was not associated with an anastomotic leak (p = 0.82), or operative blood loss (p = 0.54) but was associated with an increase in the operative duration [ß = 21.42 (95% confidence interval = 1.16, 41.67) p = 0.04]. CONCLUSIONS: Among patients undergoing LAR for rectal cancer, OPF use was associated with an increase in operative duration without any impact on the rate of anastomotic leak.